AB0586 OCULAR ISCHEMIC SYNDROME CAUSING ACUTE BINOCULAR VISION LOSS IN THREE PATIENTS WITH TAKAYASU ARTERITIS TYPE V: A THERAPEUTIC QUANDARY
Authors: A. Krishnan, U. Dhakad, P. Dogga, J. Dixit, A. Pm
Journal: Annals of the Rheumatic Diseases (2022)

Background Ocular Ischemic syndrome (OIS) is a rare manifestation in Takayasu Arteritis (TA) which can cause irreversible retinal ischemia and neovascular changes. Ocular Ischemic syndrome denotes hypoperfusion of both anterior and posterior segments of eye and orbital structures as a result of common/internal carotid artery occlusion 1,2 . Although described as a chronic phenomenon, we report three young female patients, diagnosed Takayasu Arteritis Type V (Angiographic Classification) who presented to us with acute binocular loss of vision which were managed with individually tailored approaches to restore vision. Objectives 1.To elaborate on three patients diagnosed Takayasu Arteritis type V presenting with acute onset binocular vision loss and discuss critical aspects of management in OIS. Methods Case series of three patients of TA satisfying 1990 ACR classification criteria. Results 18-year-old female presented with acute onset painless loss of vision in both eyes and severe vertigo. She appreciated hand motion on visual acuity testing. She was started on Methotrexate (MTX)and Prednisolone (PSL). In view of acute vertebrobasilar and carotid insufficiency, she underwent bilateral carotid and vertebral angioplasty. She tested 20/80 on visual acuity in both eyes and ambulated without support by two weeks after procedure. 15-year-old female presented with episodic vertigo, amaurosis fugax and claudication of both upper and lower limbs. She was kept on MTX and tapering doses of PSL and when dose of PSL reached less than 0.25mg/kg, she developed acute binocular vision loss with absent pupillary reflexes. Visual acuity testing revealed perception of hand motion in both eyes which improved to 20/40 within 2 weeks after increasing steroid dose to 0.5mg/kg and tocilizumab. 14-year-old female presented with acute binocular painless vision loss with previous history of limb claudication. Examination revealed no light perception on visual acuity testing in both eyes with absent pupillary reflexes. She was started on tapering doses of PSL and MTX. Also, she underwent a bilateral carotid and vertebral artery angioplasty. By first week, she could identify hand motion in both eyes and is continued on inpatient care. Conclusion We suggest that combining vascular surgical and pharmacological intervention in acute vision loss in TA may restore vision, even in active disease. Prompt follow-up and wider sample size is needed to draw insights into ocular involvement in TA. References [1]Peter J, David S, Joseph G, Horo S, Danda D. Hypoperfusive and hypertensive ocular manifestations in Takayasu arteritis. Clin Ophthalmol 2010;4:1173-1176. [2]Peter J, David S, Danda D, Peter JV, Horo S, Joseph G. Ocular manifestations of Takayasu arteritis: a cross-sectional study. Retina. 2011 Jun;31(6):1170-8 Figure 1. Picture attached showing a)Fundus angiogram – increased foveal avascular zone b)Fundus image -ischemic changes c)CT Aortogram -Bilateral Carotid and subclavian stenosis Table 1. Characteristics of patients of TA with acute binocular vision loss Age Duration(years) Absent peripheral pulse Hypertension CRP levels CT aortogram involvement TA type Fundus angiogram findings Fundus examination 18 1 Both brachial and radial No High Both proximal subclavian arteries, common carotid, Infrarenal aorta, coeliac and superior mesenteric arteries V capillary non perfusion areas Normal 15 2 Both brachial, radial, right popliteal and Dorsalis pedis. Yes High Both subclavian arteries, common carotid, renal and iliac arteries with &gt;50% narrowing of abdominal aorta V capillary non perfusion areas Grade II Hypertensive retinopathy 14 4 Left Brachial and radial Yes Normal Both subclavian, renal, iliac arteries and &gt; 70% diffuse stenosis of bilateral carotids V increased foveal avascular zone, capillary non perfusion areas Cotton wool spots, venous engorgements Disclosure of Interests None declared